Otolaryngology Coding Alert

Payer preference still drives 59/X decision.

Coders confronted with claims in which they need to provide evidence of distinct procedural services have several issues to sort out.

And since 2015, there’s been another factor for coders to consider when deciding on modifier 59 (Distinct procedural service) coding.

Since the introduction of the X modifiers two years ago, the coder is tasked with two goals:

1. Deciding whether a payer will consider a procedure “distinct,” and
2. Checking which type of distinct procedural service modifier the payer accepts.

Fortunately, we’ve got answers from some top-notch experts on distinct procedural service coding, which should make your next modifier 59/X claim go over smoothly. Check out this update on the new information you’ll need to ace each modifier 59/X coding claim.

Ask Payer About 59/X

Simply put, modifier 59/X applies “when two services that are usually bundled are not bundled for a specific defined reason,” explains Marcella Bucknam, CPC, CPC-I, CCS-P, CPC-H, CCS, CPC-P, COBGC, CCC, internal audit manager with PeaceHealth in Vancouver, Wash.

Modifier 59/X “lets payers know that even though these services are normally not billed separately from one another, in this case it is appropriate,” confirms Yvonne Bouvier, CPC, CEDC, senior coding analyst for Bill Dunbar and Associates, LLC, in Indianapolis, Ind.

For official guidance on which codes are eligible for modifier 59, check out the Correct Coding Initiative (CCI) edits, which Medicare publishes quarterly to update the code sets that you can separate with modifier 59/X. Learn more about CCI edits at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html?redirect=/nationalcorrectcodinited/.

X factor:  Medicare created the more specific X modifiers to replace the vaguer modifier 59 descriptor because they were not comfortable that the 59 modifier was being used only when appropriate. The X modifier forces the coder or physician to tell Medicare why the two codes should be unbundled and paid separately in this case.

The X modifiers are:

• XE: Separate encounter (A service that is distinct because the provider performs it during a separate encounter)
• XS: Separate structure (A service that is distinct because the provider performed it on a separate organ/structure)
• XP: Separate practitioner (A service that is distinct because a different practitioner performed it.)
• XU: Unusual non-overlapping service (The use of a service that is distinct because it does not overlap usual components of the main service)

Best bet: Check with your payers if you are uncertain about their stance on modifier 59/X. Some private payers might prefer that you still use the 59 modifier. Experts say that you should opt for modifier 59 unless you have specific guidance from a private payer — or a local coverage determination (LCD) or national coverage determination (NCD) for a Medicare payer.

“My recommendation would be to use modifier 59 for all payers unless instructed to do otherwise,” Bucknam says.

Bottom line: Some payers recognize the X modifiers, while others do not. If you’re unsure of a payer’s 59/X stance, contact them and check to be sure.

Unbundle Under This Quintet of Circumstances

As for when to use modifier 59/X, the main reasons you might be able to unbundle two bundled services are:

• The provider performed the service on a different part of the body. If the payer requires an X modifier in this instance, you’ll choose the XS modifier, Bucknam says.
• The provider performed the service during a different session. If the payer requires an X modifier in this instance, you would opt for the XE modifier, Bucknam confirms.
• The services, while occurring during the same encounter, involved separate practitioners. If the payer requires an X modifier in this instance, you would opt for the XP modifier.
• The provider performed two “timed” services during the same encounter, but provided those services sequentially. If the payer wants an X modifier, choose XU in this case, Bucknam confirms.
• A diagnostic procedure that is the basis for a therapeutic procedure during the same session. “There isn’t a great X modifier for this one,” Bucknam laments. If you are unsure of your payer’s modifier 59/X stance on these encounters, contact a rep before submitting the claim.